HomeMy WebLinkAbout0098 SKATING RINK ROAD - Health (2) q8 skATnrc2
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No—al Fas.... ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA
OF.............
. .
ApplirFatiuu -fair Dii uial 10orbi Towitrurtiou Vrrmit
Application is hereby made for a Permit to,Construct ( ) or Repair ( an Individual Sewage Disposal
System at:� J ry- ��� _
C.
- - ••••-------- ------ - ...................................................
A�^a L o Address or Lot No.
- -• --..----�--�W•- -~ -•- -
wner — Address
a .. •-••--------------------------------•------
nstaller Address
Q Type of Buildi g Size Lot----------------------------Sq. feet
U Dwelling No. of Bedrooms___________________________________________Expansion Attic ( ) Garbage Grinder ( )
aq Other—Type of Building __________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures ----------------------------------------------------------------------------------------------------------------------------------------•••-•-------
W Design Flow............................................gallons per person per day. Total daily flow----........................................gallons.
WSeptic Tank—Liquid capacity............gallons Length---------------- Width_._.._._. Diameter__-__---__-____ Depth--_-__-_--__---
x Disposal Trench—No_____________________ Width-------------------- Total Length.................... Total leaching area........------.___._sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet____________________ Total leaching area------------------sq. it.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date_____---------------------------------..
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..----.______-_-_-_____-
G14 Test Pit No. Z................minutes per inch Depth of Test Pit.................... De th to ground water__-_---_________-__-_---
t� ---------------------------------
C
O Description of Soil---------------------------------- `
x
----------------------- ------------------------------
U -------------------------------------------------------------------- '
W ------ - --- - - -- --------- ------- ---------------- - .. .-- ---•----- ---------
- -------------- - - --
U Nature of Repairs or Alterations—Answer when applicable._- 2__-
-------------------------------------- --------------------------------------------------------------- ------- --- - - - ------------------------------------------------------
Agreement: ,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by th board of health.
igned-- --- ---- ---- - ------------------------------------
- Date
Application Approved BY �. ------------- j, �a � `
Application Disapproved for the following reasons-------------------------------------- --------------------------------------------------- D--------------•--
-------------------------------------------------------------------------------------•------------------- ----------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
4-.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA
......OF.- .......-........... ....#.:
Appliration -for Ditipufitt1 Works Tonstrurti� rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
� ����-- --� _
------ -KOJ
---------------------- -----------
rL o Address u, f or Lot No
+�.-
. �-
Wnera ----- Address- -- •• --•--• •.-- ----------- ----------------- .................. -----------------------------------------..
? nstaller Address
d Type of Build Size Lot ._... Sq. feet
U D.welling No. of Bedrooms......................_.__..... ._. ._:-_-.Expansion Attic ( ) Garbage Grinder ( )
aOther—Type ;of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures
W Design "Flow.........................
....:.::'---_-•_______-----•--gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity---_---._.gallons Length................ Width................ Diameter.......--------- Depth................
x Disposal Trench—No..................... Width-------------------- Total,Length-----............... Total leaching area........------.-----sq. ft.
Seepage Pit No..........:.......... Diameter-------------------
. Depth below inlet------------_--------Total leaching area......_...........sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results`' Performed bY........................................................................... Date---------------------------------------"
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-.--_---..--.---_.-.....
44 Test Pit No. 2................minutes per inch Depth of Test
Test Pit.................... De to ground water__.-_.--_-_--___--.._...
---------------------------- «.L ---
D Description of Soil------------------------------- "r --.-y✓_.... ..........................................................
x �- - ------- . .....
W ------------------------------------------------------------------- .. �`,�-------.�.; - * --- `------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------- --------•---- ----
---
Ux Nature of Repairs or Alterations—Answer when a livable.-'. s: - �� -------
P PP �-------------------------------------------
Agreement: '
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been 'ssued by4 h board of health.
J-19igned. : • --•----•----•----- ---•-•------•--•••--••--••--•---••-
Date
Application Approved BY--- ------ ---- = -- �D
Application Disapproved for the following reasons---------=--------------------------- ------ -------------•-------------._.................•--••-....--_._...
.......................••----....---------•--•----------------•-•-•-•-••-•-----------•----•-------------------•--•-•----------------...=-------•-•-•••-•----------------•--- -::----------------------
Date '
PermitNo................. --•-----•• ....................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHU-SETTS
r BOARD OF ALTH
....OF............... . ' -...............
.........
Trrtifira#r of ClIntViiatta
H ,TO E FY, That Clae Individual Sewage Disposal S .stern:constructed ( ) or Repaired ( )
*..
by--- -• --r------- ---•- - -; -- -------------- --• -------- - ---------- -4;-- - --{---------`---------
Ins er
at... _.. ..._: . c. ---- ......... . -- ----•-..--•--
ha een installed in accordance with,,the provision of Article I f The State Sanitary Code as ibed in the
4.`1 ,g..1
application for Disposal Works Construction Permit l�o_________________ ______________ dated....._., ... "'"`"........._..__..
THE, ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM: WILL FUNCTION SATISFACTORY.
DATE = ----:- ... .Inspector.....................................................................................
` THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF ALTH
• ..OF...........
No.._.. ...... `
l.... ...... !' FEE---... ............
%Vivoli ork,a witrur#ion Vrrutit
Permission is hereby granted•--- -- -- ••-•----••- •''ri .................. ......................................................
to Constr t ) gtrair an Indi al ew stem at No...."
No.-� t � s - ---- --- -----
Street
"
as shown on the application for Di posal Works Co struction Per
•. - - --
DATE- . .
/RREN.
oard of Hea thFORM 1258 BBS & W NC.. PUBLISHERS